ECONOMYNEXT – A widely shared blog post written by Executive Director & Fellow of the Institute of Health (IHP) Dr Ravindra Rannan-Eliya earlier this week called for fresh thinking in Sri Lanka’s approach to containing the COVID-19 as the number of confirmed cases surged past 500.
Calling this surge – despite four weeks of curfew – a totally avoidable policy failure, Dr Rannan-Eliya said: “If accountability meant anything in this country, there would have been consequences for those involved in setting the health response.”
However, Dr Rannan-Eliya was quick to clarify that he did not believe President Gotabaya Rajapaksa was to be blamed for any shortsightedness on the part of the government.
“It is hard to avoid the conclusion that at the root of the failure was a mindset unable to rise to the urgency of the hour, to fully understand the challenge we face, and to think outside the box,” he wrote.
The following is a Q&A EconomyNext had with Dr Rannan-Eliya today on his views on Sri Lanka’s response to the pandemic as a public health expert as well as an economist.
EN: Now that the curfew has been lifted at least partially in many parts of the island, what steps can the government take, if any, to prevent a mass outbreak? Especially in light of the situation at the Welisara navy camp which seems to have escalated.
Dr RR: No single intervention will be adequate to manage COVID, as we have seen with the cases of local transmission during curfew.
To prevent epidemic spread without a lockdown, we need the full combination of (i) effective isolation/quarantine/contract tracing of all cases and their contacts; (ii) an aggressive testing program that involves many elements including testing all ICU admissions, all pneumonias, all OPD patients with certain symptoms, etc; (iii) social distancing measures such as preventing large gatherings, increasing distance between people, etc, (iv) face masks, and (v) other measures. Nobody knows how effective each of these are in isolation and none of them are adequate by themselves, so we need to do all of them.
Strict border controls to minimise entry of the virus. This will include testing all arrivals, and initially a 14-day quarantine too, though we may be able to modify that later.
EN: The authorities, though in large part have been commendable in their approach to containing the virus, have indicated a disconcerting willingness to shift the blame to an “undisciplined” public, despite some questionable policy decisions on the part of the government. What are your thoughts on this as an expert? Is there more the government can do to contain the situation rather than depending on the continued compliance of an economically and perhaps emotionally frustrated public?
Dr RR: Public health at its core is about understanding and working with human behavior, and not treating people as robots. A competent public health response cannot blame people for its failure – it only indicates the policy itself was badly designed. Blaming the public is an admission of failure. There are bound to be problems, but the responsible action is to monitor, evaluate and adjust the policy to make it work better. For example, if home isolation doesn’t work, either mandate quarantine or bring in measures to enforce compliance. Australia realised this, so it made quarantine mandatory. Singapore had the same problem, but it also allowed home isolation with very strict controls including penalties, random checks and electronic tagging. Any measures would have to be adapted to our context, so I am only saying we need to adjust and improve our response in light of outcomes.
The biggest societal challenge we face stems from prolonged lockdowns – this has never been done before. If we want to avoid that, our only option is to ensure that we have an effective control strategy that keeps the virus crushed by doing all of the measures I listed earlier. The authorities’ response to date has not been commendable, because they have put most of their eggs in the lockdown basket, and not done enough to put in the other measures, such as aggressive testing, social distancing, etc. We are now seeing the consequences.
EN: If I understand you correctly, you are of the opinion that self-isolation is impactrical, and you have said that a 14-day quarantine is not sufficient. Neither is curfew, in the long run. You have repeatedly advocated for an aggressive testing strategy. We have seen an increase – albeit limited – in testing over the past few days. Are you satisfied with the progress, or do you think more can be done?
Dr RR: It is an observation of fact that despite self-isolation and curfew, local transmission occurred in Colombo. This does not mean they should not be done, only that we need to know a lot more about getting them to work better. A problem we need to think about is whether it is feasible to expect people in poor, densely populated areas to fully comply. If we cannot get self-isolation to work effectively, like Australia, we need to quarantine in the first instance. But quarantine has its own disadvantages. There is no simple answer to this. We have to think about how we get to an optimal mix of quarantine and self-isolation, which will require many other supportive measures, and our approach will need to adjust over time.
The increase in testing this week is reactive to the large number of cases. I still do not see any evidence that the health authorities understand the need to emulate the testing strategies of places like Hong Kong, Taiwan, New Zealand, etc, i.e. move towards industrial scale testing. That larger strategy is missing – this is reflected by a lack of discussion of how we can rapidly increase testing to 5,000+ tests a day, lack of adequate guidelines provided for doctors, lack of a strategy to deal systematically with the day-to-day problems our lab colleagues are facing, etc.
EN: You have said you do not blame the political leadership for the failures observed so far. You have pointed to a continuing complacency of health officials. Is this a fair assessment of the situation, given that the government has received much criticism for what has been called its indecent hurry for elections?
Dr RR: The calling of elections is a political judgment which we have given the president in our constitution – I have no comment on this. The implementation of elections depends on the health authorities – the National Election Commission (NEC) is clear on this. As a public health expert, it was absolutely clear to me that when elections were called, that elections could not have been held in five weeks given the epidemiological reality. The health authorities should have clearly briefed the president on this and that there would be significant risks of a major outbreak during a five week election campaign – I have no idea if they did or what they said. Today, I do not believe we are in a position to safely hold elections in the next two months, since I do not believe the health authorities are yet taking the actions to allow this to happen.
If we assume that the political priority of the president is to hold elections as soon as possible, as is his right, then how do we explain the failure to put in place an effective COVID strategy? The failure makes that political goal impossible. Either the president has sought to undermine his own agenda deliberately or through willful disregard of his health advisors, or nobody on the health side has correctly advised and convinced him about the epidemiological realities of this virus and explained to him what needs to be done to allow early elections. I do not know which of these is correct.
EN: In light of the latest infection figures and trends, how much longer do you think lockdown should be imposed? What would be your advice for the government in adopting an effective exit strategy?
Dr RR: If we implement effectively all the other measures I listed above, then we can manage without lockdown, keeping it in reserve only for extreme scenarios. The experience of Hong Kong, Taiwan and South Korea prove this. Australia and New Zealand, who had much worse initial epidemics than we did, are both likely to move soon to lifting lockdowns, because they did all the other things, including aggressive testing. If we have not done so, then some level of lockdown is needed till we can put in place these other measures.
EN: Lastly, you have said that we are at the start of a very long war. What are some of the long term implications of this pandemic that you foresee?
Dr RR: We need to understand that there is no magic solution, no exit solution that allows us to forget this pandemic. It only takes one foreign arrival to create a catastrophic epidemic two months later. Until such time that a global vaccine is available, we will need to be constantly on our guard. That means continuing public health measures and border controls indefinitely. It’s up to us whether we do this with lockdowns or without lockdowns, but avoiding lockdowns means doing all the other things in full measure. All of this will require unprecedented public tolerance, so clear communication and transparency is needed – we have not done so well on this.
Globally, 2020 will see the worst economic recession since the 1930s, and the world economy may contract 5-10%. Global price deflation is a significant possibility. International travel and tourism will remain highly limited throughout this year. Even if we can get out of lockdowns, living standards here will fall because consumers in our export markets will have less money to spend, and because our migrant workers will have less money to send back.
In the longer run, I am still optimistic that the global economy will bounce back when we beat this virus. I don’t think there will be wholesale turning back from globalization, more some adjustments. Advanced capitalist economies are going to respond – they have already started – by printing money on a large scale, dwarfing what was done after the 2009 crisis. My best guess is that post-COVID this will lead to increased taxation in major capitalist economies and long term repression of interest rates – essentially what they did after the 1930s/40s. Sri Lanka will need to rethink its mistaken belief that capitalism equals low taxes, or we will continue to drop behind our Asian competitors but I fear we will not. I also suspect that contrary to initial glee in some Western countries, this crisis will further shift the global economic balance towards Asia, simply because of the better competence of governments in East Asia/Australasia in handling this pandemic. (Colombo/Apr28/2020)